Get 617 367 0400 Form

COMMONWEALTH OF MASSACHUSETTS Department of the State Treasurer Unclaimed Property Division One Ashburton Place 12th Floor Boston MA 02108-1608 617 367-0400 LOST STOCK AFFIDAVIT 1. Being duly sworn under the penalties of perjury I Name state I am of full age and reside at Street City/Town State Postal Code COMPLETE THE FOLLOWING SECTION IF YOU ARE THE ORIGINAL OWNER 2. I have not sold assigned transferred nor pledged lost stock certificate and balance nor given it away nor authorized nor empowered any person or persons corporation or association to draw any amount on same. The last time I saw the certificate it was with at on or about Date that I have made diligent search for it place that I do not know in whose possession it is nor where it could be found. ALL CLAIMANTS SHOULD COMPLETE THIS SECTION 3. In consideration of the payment to one of the said amount I agree to indemnify THE damages and expenses which THE COMMONWEALTH OF MASSACHUSETTS may sustain by reason of the turning over of the said amount to me and by reason further of its refusal hereafter to pay the said amount to any other person or persons. Stock Name Cusip Number Claimant s Signature Subscribed and Sworn to before me This day of A Notary Public in and for the County of in the State of Signature of Notary Public My Commission Expires Disk permanent Affidavits Lost Stock Affidavit. Being duly sworn under the penalties of perjury I Name state I am of full age and reside at Street City/Town State Postal Code COMPLETE THE FOLLOWING SECTION IF YOU ARE THE ORIGINAL OWNER 2. I have not sold assigned transferred nor pledged lost stock certificate and balance nor given it away nor authorized nor empowered any person or persons corporation or association to draw any amount on same. I have not sold assigned transferred nor pledged lost stock certificate and balance nor given it away nor authorized nor empowered any person or persons corporation or association to draw any amount on same. The last time I saw the certificate it was with at on or about Date that I have made diligent search for it place that I do not know in whose possession it is nor where it could be found. The last time I saw the certificate it was with at on or about Date that I have made diligent search for it place that I do not know in whose possession it is nor where it could be found. ALL CLAIMANTS SHOULD COMPLETE THIS SECTION 3. In consideration of the payment to one of the said amount I agree to indemnify THE damages and expenses which THE COMMONWEALTH OF MASSACHUSETTS may sustain by reason of the turning over of the said amount to me and by reason further of its refusal hereafter to pay the said amount to any other person or persons. ALL CLAIMANTS SHOULD COMPLETE THIS SECTION 3. In consideration of the payment to one of the said amount I agree to indemnify THE damages and expenses which THE COMMONWEALTH OF MASSACHUSETTS may sustain by reason of the turning over of the said amount to me and by reason further of its refusal hereafter to pay the said amount to any other person or persons. Stock Name Cusip Number Claimant s Signature Subscribed and Sworn to before me This day of A Notary Public in and for the County of in the State of Signature of Notary Public My Commission Expires Disk permanent Affidavits Lost Stock Affidavit.